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HomeMy WebLinkAbout2026-00049830 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 II I IIIII II III III II000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004343356 u, 1 U21 1 1 8 u, 7 U2 1 u, 1 1_12 1 U, 1 U2 1 1 11 u1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202612026-00049830 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED PRIVATE ®Y 0 N 08 18 2026 ❑AM ❑YES ®NO U1 BLUFF CITY BLVD Elgin mo /day/yr 01.47 ®PM FLOW CONDITION M I O 0/MI N E S © Elizabeth St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NISLOW 1 0) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED U1 O N u en.Alivia.A. 1 2 / yr 13-UNDER CARRIAGE 16) 2 ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 I'T1 F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 9 ALGN = ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 I,.4 COM VEH ❑ E! 1 O = SchaumburgI L 601 94 0 1 FIRST CONTACT 12 7 • __5 *If Yes.See Sidebar U1 Z BW35683 I L 2027 ' E TELEPHONE IL D JTHBK262875029037 State Farm ❑Y igi N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 1820876 SFP 13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 eu m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOA. 0 EWES 0 /1 9 6 3 Hyundai Sonata 2008 00-NONE ,�_"j t2 -_, DUE TO CRASH ❑ 2XI 0 Yr 13-UNDER CARRIAGE 10 1 E FIRE ❑ ® U2 C c ii M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 0 X ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6 .. 4 COM VEH ❑ ® Ut W FIRST CONTACT 6 7A- -',_5 •If Yes.See Sidebar C ELGIN IL 60120 C 1 EL73109 IL 2024 PEAR0 N .. IL D 5NPET46C08H386133 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Ocampo.Jose. I. 966092298 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP ui = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 01 / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z N 1 El 11 1 08/18 /2026 01 47 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 O 2 ❑ 03 28 / / ❑PM ❑Construction * Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM Maintenance U2 ❑ o1 ® 11 1 ARREST NAME Nguyen.Alivia.A. 11-601-Ax 414-1145W / / ❑PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility r 2 ❑ ARREST NAME AM 7 / / pM El Unknown work zone type 30 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 D ❑AM Workers present? ❑Y 30 41 4-Lara. Saul 401 275-Engelke / / ❑PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< c ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or I 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O 5 es pa g pe nit - } } } transporting employees in the course of their employment(example:employee c0 WO —UnItO a transporter-usually a van type vehicle or passenger car).or w L / 4. Is used or designated to transport between 9 and 15 passengers,including C}-----;----; - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or j` 1 r L i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m rl� placarding(example:placards will be displayed on the vehicle). ;p _ Not To Scale 1 I CARRIER NAME Z ADDRESS 0 T. C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate . I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE